Sunday, 13 May 2007

Last week, I posted about an alcoholic patient that I treated on the Medical Admissions Unit. I was replying to a comment that a medical student wrote, but my reply got so long I figure it deserves a post of its own. You can read the original post here.

-------------------------------------JB said...

I'm a final year student, and to be honest, I hope I never talk to a patient like that. Yeah, blah blah blah tough love, but to me that sounds like a good excuse for a dose of old-fashioned, hideous paternalism and moralising. Your patient probably doesn't need her face rubbed in the mess of her life, it's only likely to compound whatever emotional crap she is using drink as an escape mechanism from. I really like your blog and think you sound like an ace doctor (and everyone is to be forgiven for moments of getting annoyed with patients) so don't think I'm being mean, it's just my viewpoint on how I'd approach it.

You make a valid point, and one that I’ve thought about loads since that conversation with Joy. I don’t feel proud or happy about making her cry, it was not my intention to make her feel bad or to “rub her face in the mess of her life.” I could have been less dogmatic in what I was saying but the whole situation made me feel sad and angry and I felt I had to say something about it. All I did was spell out the truth.

Let me explain;

My anger stemmed from frustration. Like many addicts, I don’t think Joy thought she had a problem. I don’t think Joy could see how much hurt she was causing. I’m certain Joy didn’t have an idea of what the future would hold is she continued to neck a litre or two of spirits a day i.e. that she would die before her time in a messy, ugly and probable painful way.

Joy has got herself into a cycle of helplessness where she EXPECTS everything to be done for her. She EXPECTS that her mother will come round and pick her off the floor. That her mother will clean up her vomit, clean her bathroom and make sure her flat is habitable. She EXPECTS that the paramedics will be there every time she feels hungover. She EXPECTS that the doctors and nurses in hospital will make her feel better and help her over the symptoms if withdrawal.

Joy is RIGHT to have these expectations, these things have happened many times before and will probably happen many times in the future. I don’t think Joy saw any need to change her ways.

The point I was trying to make to Joy was that it is not FAIR to expect all these things. I wasn’t thinking about the medical side of things - after all, me, the nurses and the paramedics have been trained to deal with this sort of thing and we get paid for it. I was thinking about the grief that Evelyn (Joy’s mother) and Joy’s children were going through every single day. Joy just didn’t care about her family, and her family obviously cared deeply about her. That’s what made me mad, that’s what makes me sad. Joy continues to lie, to manipulate, to get drunk then call her seventy-something year old mother at 2am saying she’s fallen over etc… etc…

JB, obviously you are entitled to you opinions as I am mine. Yes, I was moralising. Yes as was being paternalistic, but in this particular case, do you honestly think this is a bad thing? I appreciate that it’s easy for me (a non-addict) to tell Joy to give up her addiction and I appreciate that I don’t have first hand experience of what it involves, because I’ve never had to do it. Joy has her reasons to drink and while I can sympathise that life is hard, I also recognise that there are millions of people on this earth for whom life is hard but do NOT turn to drink and manipulate those trying to help them. At the end of the day, we all have to take responsibility for our own actions and Joy was not taking ANY responsibility for hers.

I’m sure Joy had her reasons to start drinking, I was trying to make her see some reasons to stop.

Was I wrong to at least attempt to make her see how much drinking is destroying her life and the lives of those who care about her?

You’re a final-year medical student, so you probably don’t need me to tell you that alcoholic liver disease (ALD) is one of the very few medical conditions that is totally reversible. Unlike diabetes or heart failure or emphysema or cancer, people with ALD can get better, they can actually cure themselves – but only if they stop drinking.

In the last fortnight, I’ve seen five people die from decompensated alcoholic liver disease. Five dead people who would still be living today if they had stopped drinking. Of those five people, only one had family around them when they died. Four died alone, surrounded by strangers on a hospital ward.

This makes stories like Joy’s so much more tragic. It’s like that train crash that you can see coming but feel you can do nothing to prevent. I was just trying to prevent Joy from crashing, but I suspect – like so many before me – that I’ll fail.

6 comments:

Dont mind me, im an SHO in psychiatry who stumbled on to your blog tonight.

I found it quite interesting in what you wrote about the lady with alcohol dependency today. Heres my 2 cents on this...

Its good to see you are willing to tell the harsh truths to those that you see in hospital. Some doctors indeed can be a little too... "diplomatic"... in their approach with frequent or inappropriate attenders, and it sometimes does require a firm word (or ten) to get the message across. And you are correct that it is ultimately Joy herself that has to have the motivation to change her life if she wants her life to get better.

But whether you should have done this for your lady in question (and in the way you conveyed it) is debatable, id argue.

One thing i noticed in both posts relating to Joy was the fact that I never saw you asking WHY Joy was acting out in this fashion. For example:

"Each time, she comes in, her symptoms get sorted out and when she’s discharged, Joy is fine for about three or four days. Then Joy will start drinking again."

- Why does she go back to drinking?

"Joy, you KNOW why this happens. You’ve been told again and again why this happens. It’s happening because you keep drinking."

- Joy may know why she end up in hospital, but does she know why she keeps drinking?

"Your legs will get better if you stop the booze. All this will get better if you stop the booze. You could be out enjoy life if you stop the booze, but you’ve got to want to stop, Joy."

- Why will life be better if she stops drinking?

"Joy has her reasons to drink and while I can sympathise that life is hard, I also recognise that there are millions of people on this earth for whom life is hard but do NOT turn to drink and manipulate those trying to help them. At the end of the day, we all have to take responsibility for our own actions and Joy was not taking ANY responsibility for hers."

-Why?

Although you seem to have noted the chronic difficulties that Joy is having, and that the most significant factor is alcohol, you seem to have forgotten that there was a reason that Joy started drinking in the first place.

From your first post, there would be a few questions going through my mind, if I were chatting to her:

- What got her in the booze? Is she using it as a coping mechanism (to deal with mental health issues such as low modd or anxiety, adverse events in the past, poverty, poor family/social cirumstances), or was this for another reason?

- Is there a family history of alcohol dependency (=> genetic/social/poor coping strategies)?

-What would life be like for Joy if she stopped drinking?

These answers can only really be answered with a comprehensive personal and social history, and simply asking her directly.

Also, you seem to have made a few assumptions in your post regarding Joy. If theres anything ive learned in psychiatry, is NEVER ASSUME. For example:

"Here I a woman in her mid-forties who has family that obviously care about her and love her, but Joy doesn’t see that. Joy doesn’t care."

-How do you know that? Id be very surprised that she didnt care: quite the opposite in fact, but there must be a reason why she continues to destroy herself and her family. Furthermore, Joys mum and kids may be supportive, but it could be that other members are not so and could be a factor in Joys difficulties.

"Joy has got herself into a cycle of helplessness where she EXPECTS everything to be done for her."

-Do you really think she continues to drink because she knows she will get help when she is unwell? Its a possibility, but I think most people drink for other reasons than to think whats going to happen to them when theyre totally intoxicated.

Personally, I think you were quite harsh to her when you ranted at her. Although she obviously needed to know that it is her responsibility to change her own life, I dont think she needed to be told in the words you used.

I can only imagine that she would have been quite shaken by the experience. And I wonder whether things could get worse for her because of it.

We may see hundreds of people in hospital, but people tend to see a doctor every so often. And they have a memory. What worries me is that Joy will remember what you said and become more frightened about herself, and be less likely to challenge her drinking habits. She may be less likely to engage with alcohol services for fear of being judged. Even if she engages with services, Joy may be frightened to do so to a significant degree as she will be fearful of a tirade from a professional if there was a slip up whilst in rehabilitation.

Joy would have left hospital with her head full of criticism from those who she thought she could trust, and it may have contributed to her lack of confidence in general, which may be the underlying reason that she turned to drink.

One point that ive not mentioned yet is the fact that alcohol dependency is just that - a dependency. It will be just as hard for Joy to quit the sauce as a "well-balanced" individual would when trying to quit smoking. So I think its harsh to think that the repeated relapses is simply in Joys hands alone. And as you know, alcohol dependency has other factors relating to it, such as denial and confabulation, and you should be more aware of that.

Of course, I do not know Joy at all, so I could be barking up the wrong tree with this one, but it could well be that Joy had been struggling with something that led her to start drinking to cope, and now has got into a vicious cycle that she cannot get out alone. What you need to find out is whats predisposing/precipitating this problem and how to break this cycle.

I appreciate you are frustrated with her, and im sure you wont be the first (or the last) person to be, but as a medical professional, you have to do whats best in the long-term for your patients, and ranting at them is probably/usually not one of them. I know you are trying to do the best for Joy, but theres other ways of dealing with this.

If i were in your situation, id be aiming to look for the underlying reasons behind her use of alcohol. This may take time, but it might save you time dealing with Joy in the long-run if you are able to find out. If you have an inkling, then id be talking to Joy about them, and working out if it makes sense to her. And then sympathetically suggestion a plan to get her back on track, explaining why this is the best way to deal with things.

It all sounds a little utopion, but theres no harm in trying. As you say, Joy has been treated in the same fashion on repeated occasions, and may expect to be in future occasions. But if you can provide Joy with an element of insight, then she might have a desire to change. If she feels that she is understood by somebody (something that she will not perceive from anyone in her life so far, probably), then she will trust you.

"Is there any point making her an appointment to see a behaviour specialist if she never turns up because she’s pissed again?" Well id argue that you should still try, if you are able to gain her trust and have an idea whats driving all her problems. We shouldnt deny an individual the care that could get her better on your own assumptions alone. Ive seen many alcoholics that looked like they would struggle for eternity, only to recover admirably with support from the alcohol services (in dealing with the alcohol and its underlying causes). The alcohol services are the experts, not you, and they know how to deal with "lost causes" better than you or me.

You want to prevent Joy from crashing, so do it. You may think you and Joys family are giving Joy all the care possible, but you might not be. Try a different approach with her, and at least give her every oppurtunity to turn her life around.

Sorry for my rant, and I hope im not sounding paternalistic myself, because its not the tone im looking for in this post! :)

(it's a rhetorical question, I can't expect you to meaningfully answer that, but think about the alcoholics you have been referred)

No matter how we write about this issue, and whatever opinion we have, we are going to sound paternalistic. In principle I totally agree with what you are saying. It is important to discover the motivations behind why people are drinking, the factors that precipitate it and work on a plan to overcome it. Sometimes, however, it takes someone 'laying it on the line' for them to change.

I have no doubt that Joy had been seen by Psychiatric services in the past. I have no doubt that she had been referred and seen by numerous Psychiatry SHO's, Registrar's.etc The difficulty undoubtedly is getting her to engage in any meaningful form of follow-up and that purely rests on her. Yes alcoholism is an addiction, yes there is dependence, yes it destroys lives when it gets out of control, but no-one can force a person to stop unless one truly wants to...

For the record, as an A&E registrar, it is absolutely frustrating seeing these 'regulars', although that shouldn't be the motivating force behind our treatment of them, no matter how appealing it is.

To the Junior Doctor, I'm sure you had read her chart and seen the previous attendances. I'm sure your rant was justified. I only hope for her sake and that of her family that it makes a difference.

Of course i wouldnt admit. in fact i knew that before even walking into the room, id think.

Im not doubting the fact that hard truths have to be said, but i reiterate that theres a better way to do it.

And again i reiterate that we should not assume. I can only go on the info given so far, so I have no idea whether she has had psych input so far. But we shouldnt just think that she already has. Furthermore, you shouldnt avoid reconsidering it when possible - people do change over time.

Theres no loss in even referring Joy to the CPN(A)s if you can gleam even a hint of motivation from her.

But as i have already said, i do not know Joys plight so i cant be more specific than that.

If all has been tried, then fair enough, Joy does have to take more responsibility. But it shouldnt be getting the Junior Doctor down and he shouldnt vent his frustrations on her. Its Joys life after all, and we are not here to judge what she does if she does indeed have full insight to her problems.

I thank both dr Ben and the anonymous psych SHO for their comments and opinions.

I posted about my rant at Joy because that situation made me think hard about what I do as a doctor and about what my role in such situations should be.

Should I not get involved and just to rule out any inter-current illness then prescribe the alcohol withdrawal regime and refer to the alcohol liaison team and move on to the next patient? Or should I – as the psychiatry SHO suggests – try and “scratch the surface” and try and motivate her to quit drinking?

I used to do the latter. I used to spend ages with alcoholics listening to their stories and trying to convince them to change. Some would just refuse to listen. Some would agree they needed to change usually with lots of tears involved. I saw both types come in to hospital again days later because of they’d gone home and hit the booze again. I got jaded and now I swing toward the former. Talking to Joy and her family once again brought into focus for me just what a destructive addiction alcoholism is.

Psych SHO is right about the alcohol dependence services being the experts with these sorts of patients. I have had lots of conversations with members of the alcohol liaison team and what they do and I have tons of respect for the job they do in difficult circumstances. Every time Joy comes into hospital and gets “detoxed,” she is referred to the alcohol liaison team. It’s not as if we don’t make the effort. Joy simply doesn’t show up to follow up appointments and carries on drinking so what can we do? I explained to Joy’s family that the desire to change coming from Joy herself and that help is available but Joy has got to want to be helped.

I don’t think Joy wants to be helped. Joy just wants to drink.

I didn’t go into Joy’s reasons because I didn’t think it’d be a worthwhile conversation at the time. Joy vomited twice whilst I examined her and despite the fact she was obviously in alcohol withdrawal she told me:

Me: “And how much do you drink now?”Joy: “I don’t drink at all doctor, I quit in January”

You could say this is “denial and confabulation” or you could say this is “lying.”

I was harsh on Joy, I know this. I’m not in the habit of speaking like that to patients (or to anyone else, for that matter). I said what I said because I don’t think Joy had any insight. By that I mean, she was putting her falls and her weak legs and the fact she was being looked after by her family down to “bad luck” and not down to the vodka. My rant came from the fact that despite having numerous discussions in the past about her drinking, she didn’t seem to understand that her drinking was her main problem; that her drinking was the cause of not only what she came into hospital for (leg weakness, nerve damage and withdrawal symptoms) but, more widely, the cause of her dire social circumstances.

This is what I was trying to make her see – it wasn’t just random anger directed at a helpless patient who already felt awful.

So, I admit to being exasperated by Joy’s story. Yes, I was judgemental and paternalistic but, looking back on Joy’s story, I still don’t think I was wrong to be so.

This is just my opinion. You may agree or disagree with me and all opinions are welcome.

Psycho babble. My mums twin sister died of 'alchohol related' problems. Her body rotted away. Slowley. Painfully. Whilst we had the pleasure of watching. As she went yellow. Her stomach swelled like she was 9 months pregnant. Then it deflated, and all the ruptured poison bled through her body (and onto the bed sheets, I will never forget the smell).She was a selfish bitch that thought every one else had a problem. She subjected her children to a horrendous childhood. She hooked up with a kiddy fiddler. He bought her booze, he fucked her kids. My mum and the rest of us told her every day what a bitch she was. did she care. No. If she hadn't been a piss head, she would have been a nothing. At least this way she could say she was a VICTIM. She could be SPECIAL. She could do anything, ANYTHING, and it wasn't her fault, she was an ADDICT, she can't help it if her boyfriend is a kiddy fiddler, IT'S NOT HER FAULT. Fuck heads, all of them. Till you have been there personally, you can have all the psycho babble you like, it counts for shit. You just give them more reasons (excuses) to be the way they are. Are you were abused, poor you, here, get drunk, fuck up your kids, yea great, cheers doc. Dr Ben. You did good. Wish more people would tell piss heads what a bunch of selfish, self centered, using, lying, cheating, abusing, self pitying c**** they are.Apart from that, have just found your blog and I think it's Brill.Sarah x